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Pres. Diosdado Macapagal Blvd., Metropolitan Park Pasay City
In Partial Fulfillment of the Course Requirement In NCM 103: RLE
PAIN ON THE LEFT LOWER QUADRANT RELATED TO SURGICAL RESSECTION
ASSESSMENT A. General Data Patient’s Initials: T, E Address: Makati City Age: 65 years old Sex: Male Date of Birth: 02/25/1947 Occupation: N/A B. Chief Complaints Pain on the right lower quadrant of the abdomen, vomiting and experiencing headache. Informant: E.J and J.J (daughter and son) Date of Admission: June 20, 2011 Order of Admission: Carried by the relative No. of days in the hospital: 14 days Civil Status: Married
Allergies: None E. He eats fruits like mangoes and bananas regularly.The patient made complaints of headeache and pain in the Right Lower Quadrant of his abdomen. He maintains his health by taking his maintenance medication (micardis) for his hypertension and (metformin) for his diabetes. During confinement the patient is on NPO because his status is post surgery. Patient moves his bowel once a day. Health Perception – Health Management According to the client’s son. The patient has no difficulty in eating and has a strong appetite. but only on a minimal amount. Few hours prior to Admission . 5. Fats and excessive carbohydrates and sweets are restricted from the client’s diet but he still eats food with such when he wants. 2. February 2011 – The patient and his family decided to go back to the hospital and he undergone a surgical ressection of the affected colon. Also by exercising regularly and taking enough rest. The general appearance of the patient is neat and well groomed. Colon Cancer Adult Immunization: Complete Previous Hospitalization: January 2010. he also has an executive check up once or twice a year and adheres to doctor’s orders when he consults his physician. Nutritional Metabolic Pattern Before confinement.The patient complained again of tolerable pain (pain scale 4) at the right lower quadrant of the abdomen. 2010). Patient did not experience any excessive urination and pain. Past History 1. Elimination Pattern Before confinement. Even though the client has hypertension the client likes to eat meat. he is drowsy on the day of interview but can understand questions and affirms questions by nodding. vomiting. The patient perspires a lot when it’s hot and after doing strenuous activities such as his daily walking and exercising in the morning. 6. 3. 4.The patient had experienced pain on right lower quadrant of the abdomen and they went to the hospital in Philippine General Hospital for consultation. as characterized by his son. 7. the patient drinks 4-6 glasses of water a day. 3. The family decided to immediately bring the patient to the hospital and was confined at Manila Doctors Hospital. He undergone biopsy and colonoscopy. He does not think that his condition will hinder him from functioning well. because it is encouraged by his doctor. the patient urinates for about 3-5 times a day. also he eats fishes and vegetable. because he wants to recover as fast as possible. is colorless to yellowish in color. D. also by accepting treatments and procedure. He also likes to eat rice on his meals but as much as possible he limits it to 1 cup. Childhood Illness: None Adult Illness: Hypertension and Diabetes Mellitus. especially when it is grilled. the health perception of his father is always positive. 2 weeks prior to admission. History of Present Illness August 2010 . The results strongly suggested Colon Cancer. his father still has a positive attitude and has high hopes for his recovery. 2. He now maintains his health by strictly following medication regimens and orders of his physician. even though he has chronic hypertension and diabetes and has been diagnosed of cancer last ( July 7.Biopsy and Colonoscopy at PGH Operations: February 2010 Injuries: None Medications prior to confinement: Micardis for Hypertension Metformin for DM 8. His urine. he also drinks coffee in the morning. and stool is solid brown in . he managed it by resting. System Reviews (GORDONS) 1. prior to confinement. During confinement.C.
Self perception. 4. The patient usually wakes up around 6:00 in the morning and will stay awake for a few minutes but he would tend to sleep again. in fact his condition brought his family together. On decision making they discuss it with his family.color. 6. 9. Patient is drowsy upon the interview. Cognitive-Perceptual Before confinement. 7. During confinement. 5. but still they are praying and hoping for the patient’s recovery. the patient watches TV and has small chats with his neighbors or other family members. After his surgery the patient is on complete bed rest with out bathroom privileges. by giving advice to his sons and taking care of his grand children. He had slight difficulty in sleeping on the first night of his hospitalization but it did not occur in the succeeding nights. the relatives of the patient felt sad because of his condition. Before confinement. He is not sexually active anymore. During leisure time. the patient usually watches TV. After the surgery he is temporarily dependent on his son’s decision making. During the confinement the patient activity is limited. the patient can hear them when he is being asked and he responds by nodding. Role-Relationship The patient is in a nuclear family. he also likes to read the news paper and listen to the radio. He is now retired from work. Before sleeping.Self concept Before confinement. The patient speaks Tagalog language. There is no impairment on his sense of smell.Reproductive According to the patient’s son. his son said that the patient does not experience difficulty in hearing. taste and touch. even though his sons are out of the country. His family is his support whenever he has problems. He does not experience problems in sleeping Patient does not experience any nightmares or early awakenings. The patient has good attention span and does not get easily distracted by external stimuli. It worries him a lot when they are having some family problems and misunderstandings. 8. according to his son. the patient has sufficient energy when doing activities such as routine self care and other necessary chores. And at night. the patient wakes up at around 5:30 in the morning . but his urination did not change. the patient’s son describes him as a person who is always happy and as someone who loves to crack jokes and be positive all the time. According to the patient’s son. Sleep-Rest Before confinement. . the patient sleeps around 9:00 or 10:00 pm. But after surgery his bowel movement was not active. they still maintain an open communication. the patient communicates by nodding when affirming questions. he can easily express what she wanted to say. the patient can easily get along with others and can easily make friends. He can also hear whispered words and does not wear any hearing aids. before operation he only walks from his bed to the bath room and for leisure. he can still see the optimistic side of his father despite his present condition. Activity-Exercise Before confinement. During confinement. Sexuality. The relationship of the patient to his family did not change at all. The patient uses eye glasses for reading. he has also difficulty in moving but has no changes in sensorium. patient’s son mentioned that his father sleeps almost all day in the hospital. he sees his father as someone who is very strong because he can cope up with problems and changes in his life without being hopeless. The patient thinks well before making decisions. During confinement. He finds strength from God and his family. he watches TV and reads the news paper. The patient noted alternating diarrhea (character is watery and moderate in amount) and constipation before he was diagnosed of colon cancer. During confinement. Patient is assertive. During his confinement the patient did not experience any changes or difficulty in urination nor defecation. The patient’s source of exercise is by using a treadmill about 30 minutes to 1 hour every morning. but still performs a paternal role in his family. the relationship of the patient to his family members is fine.
Coping/Stress Tolerance According to the patient’s son. but still he always thinks positive and praying for his recovery. When he was confined.10. Family Assessment Relation MI M. by means of lounging in the house or sleeping and doing leisure activities. also it is relieved when there are family members and friends that visit him. F. He does not get everything that he wants in life due to some reasons. Developmental History THEORIST Psychosexual Theory Freud AGE 65 TASK GENITAL STAGE PATIENT DESCRIPTION The patient was observed to have capable and distinct relationship with others especially to his children. like reading the news paper or watching TV. God is their source of strength. Patient’s son mentioned that he knows that his father has a strong faith in God and knows that God will always help them in everything he does. but handles it by resting.J J. 11. The patient as a father. the patient experiences stress. he still gives the needs of all the family members as much as he can. the patient is in stress. Psychosocial theory Erickson 65 GENERATIVITY VS. On the other hand. During confinement. Values/Belief Patient is a Catholic and he goes to mass during Sundays whenever he has the time. he feels unproductive.J Wife Daughter Son Age 62 36 31 Sex Female Female Male Occupation Professor Call Center Agent Nurse Educational Attainment College Graduate College Graduate College Graduate G. His family is always there for him to give what he needs and wants not just materially but through comfort and care all the time. He feels success because he contributes to the world by being active not just in their home but in the whole community according to his son. though he was retired from his work. and also according to his son. STAGNATION . the closeness with his family and other significant people bind much more than before since he suffered from pressure and stressed. that’s why he feels useful and accomplished. The patient always wanted his children to have a good life.Familial Illness Maternal: Diabetes and Cancer Paternal: Hypertension H.J E. but he relieves it by resting and being positive. Patient’s son said that they believe that everything happens for a reason and God would not give us challenges that we cannot resolve. sometimes he goes out with the family. Heredo. now he’s confined. being an optimist surely relieves the stress of his father. according to his son.
As of now. and one’s he discovered it he value it for the sake of others. his children answer all the questions for us. pinkish in color. As a n older adult he is very much open to other. Physical Assessment Date: July 4.18kg/m2 Vital Signs Temperature: 36. his family is the one who gives and always finds time to talk to him in order to reduce his anxiety and loneliness due to his condition. clean good capillary refill in 2 seconds C. he really depends on himself alone but when it comes on major decisioning. I. His actions are very careful for him to prevent consequences that might affect his loved ones according to his children. He’s very accountable and do everything under the rules and regulations. in terms of decisioning. He accepts everyone’s opinions and suggestions.9 ˚C PR: 78 bpm RR: 20 cpm BP: 130/70mmHg Regional Examination A. He always relies on his family whenever he has difficulties by softly speaking. When he was not confined. Nails I: P: fingernails have convex curvature.2011 (4:00pm) Height: 152. absence of edema when skin is pinched. it returns back to original form in a 4 seconds poor skin turgor B. less hair on parietal area P: uniform warm temperature. intact skin. When they have excess money they give solicits to their barangay according to his family it will help.4 cm Usual weight: 180 lbs Actual Weight: 190 lbs Ideal Body Weight: 19. He’s the one who has the initiative to discover new things. He respects his fellowmen on what beliefs they are believing and owed to. regardless of it’s impact on him. and through nodding . he consults his family. he let the reality speak for itself. He complies on all the given laws. Head and Face . to become their community a productive one. Skin and Hair I: Skin color is brownish Some macula light brown in color on both arms dry skin unevenly distributed hair.Cognitive Theory Piaget 65 FORMAL OPERATIONAL STAGE Moral Theory Kohlberg 65 POST CONVENTIONAL MORALITY STAGE Spiritual Theory Fowler 65 Conjunctive faith During the interview. The patient loves all the significant persons that is very special to him.
transparent cornea. no tenderness on the sinuses G. constricts at far objects and dilates at near objects. smooth. pinkish mucosa. tongue is at the midline. able to purse lips. bulbar and palpebral conjuctiva are pink in color. Eyes I: E. midline nasal septum. can see peripheral views. grayish-blue lens of the eyes constricts in direct and indirect consensual response. no edema or hollowness of the eyes evenly distributed eyebrows. nasolacrimal duct. no lesions. reddish tonsils presence of gag reflex P: . round pupil. rounded shape. elastic. able to blink. uses full dentures uvula is at the midline between tonsils. Mouth and Pharynx I: symmetric contour. no lesions. pinkish lips gums are pinkish in color. intact skin. covered eye doesn’t move. eye blinks with corneal sensitivity.I: P: smooth. Nose I: P: symmetric. cannot hear ticking of watch can hear normal voice sound no tenderness or edema same color as the face. black. converges. absence of nodules or masses D. presence of cilia. Ears I: P: F. eyes are coordinated. no edema. sac. cannot read newsprints Presence of rashes on back of the ear no impacted cerumen. watery eyes no tenderness of the lacrimal gland. same color as the face. outward curl of eyelashes. symmetric facial features and movements. normocephalic.
able to move the neck in several directions. no tenderness. masses. Anterior I: no deformities. inverted umbilicus. midline trachea Kyphotic posture Straight spinal column Spine vertically arrange No deformities and contracture No swelling No lessions no tenderness. no scars P: no masses. no enlargement of thyroid gland palpable submandibular lymph nodes. masses H. Posterior I: Kyphotic posture. symmetric contour. no masses or lumps J. refused . Neck I: P: I. Thorax and Lungs A. no tenderness P: vesicular over lung area A: ronchi heard K. no problem with chest excursion. Spine I: P: no abnormal swellings or masses. fremitus over the lung region Per: resonant over lung area except between scapula A: ronchi heard B. no nodules. 7 borborygmic per minute absence of arterial bruits and friction rub Per: Not assessed. Abdomen I: Skin over the abdomen is brown in color. thyroid gland moves up when swallowing. Cardiovascular/Heart I: no lifts or heaves no vein distension and engorgement no visible pulsations P: PR is 78 bpm A: pulse beat is best heard at the apical area L. refused Pal: Not assessed. position of the spine is at midline Pal: No lumps. no lesions. round. distension presence of lesion swelling at the left lower quadrant incision on the left lower quadrant A: audible bowel sounds.
they use insecticide to kill it. hospitals. The client is currently living at a 2-storey house. Their electricity is supplied by MERALCO. At 7 PM he will watch television again then around 9 or 10 in the evening he will go to sleep. extend N. market place are easily reach. refused P.1 hour. HK. jeepneys. washing as well as for their drinking. Environmental History The patient is residing in a quiet and peaceful place of Makati City with a mixed and owned type of house. drugstores. Rectum and Anus Not assessed. Extremities I: equal size of muscles. male Genitals I: has presence of rugae no lesions no tenderness no discharge with presence of pubic hair in the pubic area O. pedi . and Vietnam. no tenderness ROM: able to flex. they used it for bathing. no contractures. he will watch television for 2-3 hours then go for an exercise for 30 mins. He will rest for 15-30 minutes. no tremors. Transportation is not a big deal. Appearance and Mental Status Well-oriented Body build fits age and lifestyle No body and breath odor Appropriate responses Thoughts are relevant Conscious Alert and awake No signs of distress II. if not he will go out to chat is friends and neighborhood. hyperextend. at 6 PM he will have his dinner. reading newspaper. Some vectors can be seen in their house. Their house has 3 bedrooms with good ventilation (5 windows for the whole house). equal muscle strength. Afterwhich. no swelling of joint Presence of macula Presence of scratches P: no edema. 5 PM he will read newspaper then he will listen to the radio. Social Affiliation: None Client’s usual day like: He wakes up at around 5:30 in the morning and then eats breakfast. After eating. Their water is MAYNILAD. listening to radio Vices: None Lifestyle: The client has sedentary lifestyle. using treadmill for 30 mins-1hr. and then adequate living room and dining area. Churches. and then take a nap for 2-3 hours.M. around around 1-2PM he will watch television again. Rank in the family: Father Travel: The client went to USA. 4 comfort rooms with a flushed-type system. Educational attainment: College Graduate III. Personal/Social History Habits: Watching television. then he will eat for his lunch. flaccid. Sometimes he will water their plants and then.
Food is properly kept and covered or else place in refrigerator. The collection of garbage in their community is twice a week. tricycles are very much available. .cabs.
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